Coronial

62 results for laparoscopic surgery

WAhome2013-05-16

Inquest into the Death of Levissianos, Katina

55y · Female·Aspiration of Gastric Contents in Association with Gastric Necrosis in a patient…

…cant vomiting warrants urgent surgical review. Key clinical lesson: GPs require education about bariatric surgery complications, specifically that excessive vomiting mandates urgent specialist review and possible device…

general surgerybariatric surgerycommunicationdiagnosticamoxicillin/clavulanate
NSWhospital2019-03-22

Inquest into the death of Patrick THOMAS

52y · Male·Intestinal failure/sepsis arising from venous ischemia as a result of superior m…

…stinal failure and sepsis following an accidental division of the superior mesenteric vein (SMV) during laparoscopic surgery for colon cancer at Kareena Private Hospital on 9 October 2013. Despite emergency repair with a…

colorectal surgeryintensive carecommunicationsystem
NThospital2018-09-21

Inquest into the death of David Fensom

67y · Male·multi-organ failure due to septic shock consequent on faecal peritonitis due to …

…abdominal pain is disproportionate to examination findings, particularly in patients with prior abdominal surgery. Communication with family was also severely deficient, with no explanation of death provided until eight…

general surgeryemergency medicinediagnosticcommunicationfentanyl
NSWhospital2025-08-14

Inquest into the death of Margaret Mariani

88y · Female·Complications of cholecystectomy surgery

Margaret Mariani, 88, died from complications of laparoscopic cholecystectomy for gallstone-induced pancreatitis. An iatrogenic small bowel perforation, likely cause…

surgerygeneral surgerycommunicationdelayfentanyl
SAhospital2016-08-03

Coroner's Finding: LAMBROPOULOS Andrea

34y · Male·hypoxic-ischaemic encephalopathy following laparoscopic bariatric surgery with i…

Andrea Lambropoulos, a 34-year-old man with morbid obesity, sleep apnoea, and ischaemic heart disease, died following sleeve gastrectomy. He was admitted to HDU rather than ICU post-operatively. In HDU, he experienced re…

bariatric surgeryanaesthesiacommunicationdelaymorphine
NThospital2019-04-16

Inquest into the death of Ali Achmadun Djawas

70y · Male·multi-organ failure due to septic shock consequent on faecal peritonitis due to …

…tomy on 13 March 2017 for a suspicious ileo-caecal lesion. Biopsies were benign, CT imaging negative, yet surgery proceeded. Critical failures included: inadequate informed consent (risk of death not disclosed despite b…

colorectal surgerygeneral surgerydiagnosticcommunicationmethylnatrexone
TAShospital2019-04-16

Coroner's Finding: Hill, Phillip John

82y · Male·sepsis due to faecal peritonitis due to suture failure of bowel anastomosis foll…

…is due to faecal peritonitis following anastomotic breakdown after right hemi-colectomy for colon cancer. Surgery was appropriate and proceeded without incident. Five days post-operatively, he developed symptoms of bowe…

colorectal surgerygeneral surgerydelayamiodarone
VIChospital2025-10-28

Finding into death of Kenneth James Anderson

85y · Male·Liver ischaemia and portal vein thrombosis complicating emergency cholecystectom…

… ischaemia and portal vein thrombosis, leading to multi-organ failure. The coroner found no want of care: surgery was necessary (patient would have died of sepsis), consent was appropriate, preoperative imaging was stan…

general surgeryintensive careantibiotics
WAhospital2011-05-12

Inquest into the Death of Walden

68y · Female·Multi-organ failure associated with septic shock following duodenal perforation …

…a Hana Walden, 68, died from multi-organ failure and septic shock following duodenal perforation during laparoscopic surgery at Swan District Hospital on 8 May 2008. Surgery was performed to remove her gallbladder, which…

general surgerygeneral practicediagnosticcommunicationpethidine
VIChospital2026-02-24

Finding into death of Julie Anne White

59y · Female·Complications of a pseudo-obstruction on a background of previous anterior resec…

Julie Anne White, 59, died from complications of pseudo-obstruction following previous sigmoid volvulus resection. She had intellectual disability, dementia, schizophrenia, depression, and chronic bowel dysmotility. Admi…

general surgerypalliative care
VIChospital2018-10-18

Finding into death of Maxwell Norman Campbell

68y · Male·pulmonary thromboembolism in the setting of recent surgery

A 68-year-old man died from pulmonary thromboembolism following revisional gastric bypass surgery. He developed multiple post-operative complications including fever, elevated inflammatory markers, and a…

bariatric surgerygeneral surgeryheparin
SAhome2014-01-31

Coroner's Finding: ROWAN Marjorie June

52y · Female·ischaemic and hypertensive heart disease

… heart disease. She was prescribed dothiepin 225mg daily for depression management. Following gallbladder surgery in April 2009, she had deranged liver function tests (elevated GGT and ALP). The coroner examined whether…

psychiatrygeneral practicedosulepin
VIChome2025-09-17

Finding into death of Robert John Robinson

74y · Male·Pulmonary thromboembolism in the setting of deep leg vein thrombosis

A 74-year-old man died from pulmonary thromboembolism with deep vein thrombosis 10 days after elective umbilical hernia repair. He received appropriate VTE prophylaxis (mechanical and pharmacological) intraoperatively an…

surgeryanaesthesiacommunicationenoxaparin
TAShospital2017-06-16

Coroner's Finding: Baldock, Andrea Eileen

46y · Female·combined effects of aspiration pneumonia due to gastroparesis following sleeve g…

…onitored post-operative care plan as a significant deficiency. The case illustrates that weight reduction surgery carries non-trivial risks and should follow exhaustion of non-invasive options.

general surgerygastroenterologysystemdelay
SAhospital2020-10-30

Coroner's Finding: VELT Hank Jakob

65y · Male·ischaemic and hypertensive heart disease with contributing acute cholecystitis (…

A 65-year-old man with hypertension presented with acute cholecystitis, underwent laparoscopic cholecystectomy, and initially recovered well. On post-operative day 7, he experienced chest pain radia…

general surgerycardiologydiagnosticcommunication
WAhospital2013-01-17

Inquest into the Death of Mckay-Hall, Julienne Maria

46y · Female·Complications following cardiorespiratory arrest in association with an air embo…

A 46-year-old woman died from air embolism during a gastroscopy to manage complications from bariatric surgery. The initial laparoscopic sleeve gastrectomy on 9 November 2007 had a staple misfire that was inadequatel…

general surgerybariatric surgerydiagnosticcommunicationmorphine
SAhospital2001-05-04

Coroner's Finding: ROACH Dawn Ruth

45y · Female·Multi-organ failure due to septicaemia and peritonitis due to faecal leakage fro…

…re following failure of a loop colostomy created for management of an anastomotic leak after bowel cancer surgery. The initial anastomotic leak (1.5 cm) was contained and reasonably managed conservatively. However, the …

colorectal surgerygeneral surgeryproceduralcommunication
QLDhospital2007-08-26

Fitter, Maureen

60y · Female·Cardiac tamponade due to ruptured heart due to total parenteral nutrition due to…

… TPN fluid leaking into the pericardium through a PICC line inserted to provide nutrition following bowel surgery. The PICC line was inserted under image intensification with appropriate technique and placement at the S…

colorectal surgerygastroenterologytotal parenteral nutrition
QLDhome2014-08-11

Crane, Sylvia - Non-inquest findings

66y · Female·Pulmonary thromboembolism due to renal vein thrombus secondary to renal cell car…

…umour thrombus originating from renal cell carcinoma. She had a five-month delay in scheduling Category 1 surgery for nephrectomy due to systemic waitlist management failures at RBWH. Although the rapid disease progress…

urologygeneral practicecommunicationsystem
VIChospital2012-04-19

Finding into death of Selvamalar Murugathasan

43y · Female·Acute thrombosis of a prosthetic mitral valve

A 43-year-old woman with prosthetic mitral and aortic valves due to rheumatic heart disease died from acute thrombosis of her prosthetic mitral valve following cessation and recommencement of warfarin for IVF treatment. …

cardiologyintensive carecommunicationsystemwarfarin

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